Pelvic floor dysfunction is one of the most commonly misunderstood conditions seen in clinical practice. Many people assume that all pelvic floor issues are caused by weakness, but this is not always the case.
In reality, pelvic floor dysfunction typically falls into two distinct categories:
- Overactive (tight, non-relaxing)
- Underactive (weak, poorly coordinated)
Understanding the difference is critical, as the wrong type of exercise can worsen symptoms rather than improve them.
Who We Treat
In clinic, individuals presenting with pelvic floor dysfunction come from a wide range of backgrounds. This includes postpartum women returning to exercise, athletes such as weightlifters managing high intra-abdominal pressure, older adults experiencing urinary incontinence, and men following prostate surgery.
Despite these differences, the starting point for treatment remains the same—identifying the type of dysfunction present and tailoring the approach accordingly.
Overactive Pelvic Floor (Tight & Non-Relaxing)
An overactive pelvic floor is characterised by excessive tension through the muscles. This often presents as pain, discomfort, or difficulty relaxing the pelvic floor.
This is not a strength issue. Strengthening exercises are generally not appropriate in the early stages and can aggravate symptoms. Instead, the focus is on relaxation, breathing, and reducing muscle tension.
Recommended: 3 rounds of 30 seconds per exercise
Exercises:
- Diaphragmatic Breathing
The diaphragm and pelvic floor work together. A proper inhale allows the pelvic floor to relax and lengthen.
Cues: “Breathe into your ribs, not your chest”, “Let your pelvic floor gently drop as you inhale” - Child’s Pose with Pelvic Floor Relaxation
Opens the pelvic outlet and promotes passive relaxation.
Cues: “Knees wide, hips back”, “Focus on slow breathing into the lower abdomen” - Happy Baby Pose
Gently stretches the pelvic floor and surrounding muscles, including the hips and adductors.
Cues: “Let everything soften—no gripping”, “Avoid pushing or straining”
Underactive Pelvic Floor (Weak & Leaking)
An underactive pelvic floor is typically associated with urinary leakage, reduced muscular support, and a feeling of heaviness or pressure.
In this case, the goal is to restore strength, coordination, and endurance of the pelvic floor muscles, while also integrating them into functional movement.
Recommended: 3 rounds of 15 repetitions
Exercises:
- Pelvic Floor Lifts & Lowers
Targets the main “hammock” of the pelvic floor, as well as urethral and anal control.
Cues: “Lift as if you’re going up an elevator”, “Lift as if you’re stopping passing wind”
Note: Controlled relaxation between repetitions is essential. - Pelvic Glute Bridge
Integrates pelvic floor activation with the glutes and core for improved functional strength.
Cues: Initiate pelvic floor lift first, then lift hips. Control the lowering phase and relax on the way down. - Functional Movement (Sit-to-Stand)
Trains pelvic floor activation during real-life movement, where symptoms often occur.
Cues: “Engage before you move”, “Exhale as you stand”
Are Kegels Always Helpful?
Kegels are one of the most commonly prescribed pelvic floor exercises, but they are not suitable for every condition.
They are effective for an underactive pelvic floor where strength and control need to be developed. However, for an overactive pelvic floor, strengthening exercises such as Kegels can increase tension and worsen symptoms.
A proper assessment is essential to determine whether they are appropriate.
Common Mistakes to Avoid
Several common mistakes can delay progress or exacerbate symptoms.
- Misdiagnosing the issue
Not all urinary leakage is due to weakness. In some cases, the pelvic floor may be overactive. - Bearing down instead of lifting
Pushing downward instead of lifting can increase pressure through the pelvis and contribute to worsening symptoms. - Neglecting relaxation
The pelvic floor must be able to both contract and relax. Ignoring the relaxation phase limits recovery.
Case Study: Postpartum Return to Sport
An individual presented 8.5 months postpartum with the goal of returning to netball, a high-impact sport. Assessment indicated pelvic floor strength of 3/5 and a mild risk of prolapse.
Initial management focused on pelvic floor lifts, endurance holds, and low-impact movement. Progression included glute bridges with pelvic floor activation, controlled squat jumps, and interval jogging.
Following a structured and progressive program, the individual returned to sport with minimal leakage and improved confidence in high-impact movements.
Final Thoughts
Effective pelvic floor rehabilitation depends on accurately identifying the type of dysfunction and applying the appropriate exercise strategy.
Programs should focus on control, gradual progression, and integration into functional movement rather than isolated strengthening alone.
When to Seek Help
If symptoms such as leakage, pelvic pain, or pressure persist, assessment by a qualified exercise professional can help guide appropriate treatment and improve outcomes.
